Category: Sexual Assault

In case you missed the release of this a couple weeks ago, the Office on Violence Against Women published a white paper, Sexual Assault Kit Testing and Non-investigative Kits (PDF). Per their description: “This report presents reasons why the Office on Violence Against Women cautions against submitting sexual assault kits to forensic laboratories if the person from whom the kit was collected has not chosen to report a sexual assault to law enforcement and has not otherwise consented to its submission.” Many communities are debating the issue of how to handle untested kits right now, so it’s worth your time to both read and share with members of your SART for an upcoming meeting. It’s well articulated and well-referenced, and best of all, it’s relatively brief.

The US Department of Health and Human Services, Office on Trafficking in Persons has been offering their SOAR to Health and Wellness training to clinicians, social workers and public health professionals, and the next healthcare provider session will be on March 9th.

Contrary to the rather nonspecific name, this training specifically [E]quips professionals with skills to identify, treat, and respond appropriately to potential victims and survivors of human trafficking.

By applying a public health approach, SOAR seeks to build the capacity of communities to identify and respond to the complex needs of victims and survivors of human trafficking and understand the root causes that make individuals, families, and communities vulnerable to trafficking.

After attending SOAR training, you will be able to:

• Stop – Describe the scope of human trafficking in the United States
• Observe – Recognize the verbal and non-verbal indicators of human trafficking
• Ask – Identify and interact with victims and survivors of human trafficking using a victim-centered and trauma-informed approach
• Respond – Respond effectively to potential human trafficking in your community by identifying needs and available resources to provide critical support and assistance

The sessions are held online and in person, but to my knowledge tey are not archived, so if you want the training it must be done on the date offered. Registration is not yet available, but keep checking back for the link.

OJJDP is hosting a webinar, Understanding the Complexities of Commercial Sexual Exploitation, January 30th from 2-3:30pm ET. From the announcement:

In support of National Slavery and Human Trafficking Prevention Month in January 2017, OJJDP, in conjunction with MANY and the Wichita State University Center for Combating Human Trafficking (CCHT), will present an interactive webinar to deepen participants’ understanding of commercial sexual exploitation.

This 90-minute workshop will discuss specific circumstances that put individuals at risk of victimization and what helps them survive, and even thrive, despite experiences of abuse and exploitation.

Participants will have the opportunity to consider the pervasive impacts (biological, physical, psychological, and spiritual) on persons affected by commercial sexual exploitation and celebrate the resiliency evident in the journey from victim to survivor. Participants also will learn about tangible, intentional, and responsible actions that can be taken to support those affected.

You’ll also want to check out this recently published article from the AMA Journal of Ethics (FULL-TEXT)

The Tribal Forensic Healthcare project has 2 free, upcoming webinars: Funding for Forensic Exams–VAWA 2013 Requirements and VOCA (2/13); and Evidence Integrity–Keeping It Safe (3/14). They will both be archived if you aren’t available on those dates. CEUs/CMEs are available for both.

Register for Funding for Forensic Exams

Register for Evidence Integrity

{Once again, let me preface this by saying I am not the definitive authority on this topic. I am one woman with an opinion who provides care to adult and adolescent domestic violence and sexual assault patients. At the end of the day, you need to decide the best course of action to take for your practice and patient population. Hopefully, this spurs some discussion, where needed, as that is its intent.}

So I was asked by an FHO reader if I would comment on the best way to document the narrative portion of the history. That is, the history of the patient’s chief complaint. Always up for stepping into the abyss, I said, sure–why not? After all, it comes up in pretty much every single testimony workshop I teach.

Perhaps the best way to begin this discussion is by saying, I don’t necessarily believe there is one right way to document the narrative history of the assault. Some of you out there write down everything the patient says, verbatim. I think that’s weird, but I don’t necessarily think it’s wrong.

Why do I think it’s weird? Because I personally can’t listen to a patient and also transcribe everything the patient says. When I do that, I miss all the rich, non-verbal communication that happens, and that impacts patient care. But that’s just me. Also, most people aren’t terribly accurate at capturing every single word the patient says, which I imagine defeats the purpose of choosing that method in the first place. So for me, it feels like a missed opportunity to connect with a patient as a person (and not a crime scene or a complainant), and begin the process of assessing their well-being.

My preference is to summarize, except where my summary couldn’t possibly do justice to the patient’s account of events or state of mind (threats, fear, etc.). Then I add quotes. This gets me where I need to be to take care of this patient in the most comprehensive way possible. And since the purpose of obtaining the narrative history of the assault is to guide my exam process, focus any sample collection the patient may desire, and inform the patient-specific discharge and follow-up plan, I don’t feel like I could more effectively accomplish any of that if I wrote down what the patient said verbatim.

I do think there are some wrong ways to approach narrative documentation, though (and I see them all in my travels):

1. Having the patient write it out for you (and even worse, having them sign it). This is not medical documentation. And doing this says that the end goal is litigation rather than good quality patient care. If you want to tell me it’s to avoid inconsistencies between what the patient reported to law enforcement and what the patient tells us, I’m going to call BS on that right now–1.) not all of our patients even engage with law enforcement, and some will do so long after the exam; and 2.) I challenge people under duress to write down details of a traumatic event and then several hours later, in a different environment with different people looking over your shoulder, do it again–now see how many inconsistencies are there.
2. Obtaining the narrative history of the assault from law enforcement rather than the patient. Except in extraordinary circumstances (e.g. patient is brought in unresponsive and you take a report from the police) I can’t come up with a justification for this approach.There are reasons patients tell healthcare providers different details than they tell law enforcement–they may feel more comfortable with us; they may believe there’s a different purpose for providing the info (and there is); we don’t have a gun on our hip at the time we’re caring for them. Also, how many times have you gone into a patient’s room to get a history, and then had them provide totally different information when another physician or nursing colleague went in to see them? Exactly. People are not machines. Different questions elicit different responses, even when focused on the same event. Inconsistencies are both expected and explainable.
3. Never having it (and the rest of the medical-forensic documentation) peer-reviewed. Some sort of quality assurance/quality improvement process is a must. How do you know you are providing comprehensive, appropriate care and hitting identifiable benchmarks for quality if your work is never reviewed?

So if I was going to summarize, I’d say this: if you have a clinical rationale for documenting in your particular style, you’re probably just fine (assuming your work is also being peer-reviewed). If your approach to documentation of the narrative history is dictated by any non-clinician professionals (e.g. law enforcement or prosecutors like you to document in a certain way), or you see its purpose as being primarily for the investigation and prosecution of the reported crime, I think that’s problematic. And if your approach simply doesn’t resemble healthcare at all, well, it may be time to reassess.

OVCTTAC has a revamped website with a dedicated section to SANE-SART resources. It includes the SANE Program Development and Operation Guide, among other resources. It is a multimedia site, so there are videos, as well as archived webinars on a variety of topics. Worth perusing for sure.

The Battered Women’s Justice Project has an upcoming webinar, Nonconsensual Pornography: Circulating Sexual Violence Online. The session will be held January 24th from 2-3:30pm CT. From the website:

Pornography, much like sexual violence, is pervasive, especially in online spaces and has evolved to include content that is both consensually produced and disseminated as well as that which is not. Accordingly, in this webinar, presenter Amber Morczek will define nonconsensual pornography (often referred to as ‘revenge porn’), how it impacts victims, what is being done to address it, and how it relates to rape culture.

Register for the webinar here. Note: space is limited.

I received a question from a reader about choosing a training for prospective members of her SANE team. She had heard that there were some trainings out there that didn’t meet eligibility requirements for SANE certification and wanted to avoid them, but wasn’t sure what to look for. I agree that not only is it important to identify training that meets certification eligibility criteria, it’s also important to have some sense about quality in general (I promise you–not all SANE trainings are equal). So I encourage everyone to refer back to this guest post from 2009, which is as relevant today as it was more than 7 years ago (make sure to read the comments, too). Considering the sheer number of new subscribers we’ve had just in the past 2 months, it’s probably worth posting again, regardless. Enjoy!

{Post edited to update links.}

EVAWI just put out a bulletin on the neurobiology of trauma (PDF) that, while geared toward investigators, can serve as a good primer on the issue for clinicians, as well. From the email announcement:

…[T]his 38-page document provides basic information about the brain and explores the impact of trauma on behavior and memory. It then highlights the implications for law enforcement interviews conducted with victims of sexual assault and other traumatic crimes.  

The training bulletin was written by Dr. Chris Wilson, Dr. Kim Lonsway, and Sgt. Joanne Archambault (Ret.), with contributions by Dr. Jim Hopper. It was reviewed by experts from a variety of professional disciplines, including psychology, law enforcement, and prosecution. We hope you find it to be a useful resource, to enhance your understanding of these critical issues. 

With an understanding of how the brain responds to trauma, and an appreciation for how trauma affects memory encoding, storage and recall, we now have the potential to become truly “trauma informed” in our interviewing practices.  

I think the reference section is particularly useful for clinicians, especially those testifying as an expert on this issue. However, to be clear, I am very skeptical of most forensic nurses testifying as experts on this topic unless they know the science backward and forward–that means being able to speak to the literature that challenges some of these ideas, as well as the literature that supports it. (I feel like I’m pretty well-versed in this issue; I do not provide expert testimony on it.) Reading a monograph like this, or attending a training, does not make one an expert. It’s useful information to help understand patient behavior and the workings of the brain in the face of trauma, but proceed cautiously with how you use it in court.

Don’t forget we have a giveaway going on this week. See all the details here.

The National Resource Center on Justice Involved Women has a webinar coming up next week: The Intersection Between Prostitution, Human Trafficking, and Victimization Among Justice Involved Women. The session will be held November 1st from 2-3:30pm ET.

From the site:

It is estimated that 90% percent of justice involved women have experienced some form of victimization in their lifetime. As a result of this trauma, women may engage in behaviors that are criminalized, such as drug use or prostitution, and may be less commonly seen as “victims” by the justice system. What’s more, their vulnerability may expose them to further victimization, trauma, and exploitation — such as human trafficking.

The NRCJIW, in partnership with the Center for Court Innovation, will conduct a webinar on November 1 to explore the nexus between prostitution, human trafficking, and victimization among justice involved women. The webinar will discuss strategies that justice system stakeholders can take to identify women who may be victims of exploitation and human trafficking, address their needs, and improve their response to these women.

Register now for this informative webinar to take place on Tuesday, November 1 from 2:00 – 3:30 pm Eastern.

Good morning. I hope all of our Canadian readers had a lovely Thanksgiving. Tonight begins Yom Kippur, so I will be knocking off a bit early to get ready for services. Apologies for the lack of post yesterday. It was a federal holiday in the US, so I played hooky with my wife who had the day off. And let’s face it–the only thing I’ve read since last we spoke is about our unfortunate Republican candidate, and no one needs more to read about him. So let’s move on to things that lift us up, shall we? Namely quality education that improve our capacity as clinicians, this one from Futures Without Violence:

They are hosting a webinar, Legal Aspects of Human Trafficking for Health Providers: Case Studies and Legal Remedies. The session will be held October 20th from 3-4:40pm ET. From the site:

Description: This webinar will provide health care providers with insight into the legal remedies available to human trafficking victims. Each year, thousands of men, women, and children are held in forced labor, forced prostitution, and the commercial sexual exploitation of children. This webinar will explore the role health care providers can play in identifying trafficking victims, providing documentation, developing expert testimony, and providing affidavits for submission in legal cases. The program will cover both US citizen and foreign-born victims trafficked in the United States. Presenters will use case studies to discuss trafficking victims’ contact with the providers, including missed opportunities when victims might have been identified but were not. The speakers, both attorneys, have more than three decades of combined experience in the human trafficking field.

Learning Objectives

1. Identify legal remedies – immigration, civil, and criminal – available to trafficking victims in the United States;
2. Define the critical role that healthcare providers can play in identifying victims, providing documentation, developing expert testimony, and providing affidavits for submission in legal cases;
3. Identify human trafficking red flags through case examples of victims seeking medical care.

Presenters:

Hanni Stoklosa, MD, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA and Executive Director, HEAL Trafficking.

Stephanie Richard, JD, Policy & Legal Services Director, Coalition to Abolish Slavery and Trafficking (CAST), Los Angeles, CA

Martina Vandenberg, JD, Founder and President, The Human Trafficking Pro Bono Legal Center (HT Pro Bono), Washington, DC.

Register here.

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury have a webinar coming up this month, Unique Perspectives for Women with Traumatic Brain Injury: Gender Differences and Coping Strategies. It will be held October 13th from 1-2:30 pm ET. While I imagine it will address mild TBI specifically from combat-related activities, these issues also apply for many of our interpersonal violence patients, such as domestic violence victims. The gender-specific nature of this session makes it particularly interesting to me. Click through for details:

From the site:

The data regarding active-duty servicewomen who have sustained traumatic brain injury (TBI) suggest their experiences, aftereffects and outcomes differ from servicemen. This presentation will integrate current research and clinical expertise to advance health care provider awareness of TBI among women serving in the military. The speakers will present current evidence comparing female athletes and active-duty service members with a TBI history as well as data about servicewomen with and without symptoms from co-occurring conditions such as posttraumatic stress disorder, anxiety and chronic pain. The presenters will also address the gaps in the present knowledge base concerning gender differences and TBI.

At the conclusion of this webinar, participants will be able to:

1. Describe three ways in which brain injuries in women (including concussion or mild TBI) are unique.
2. Articulate factors that may account for gender differences in TBI incidence, severity and recovery.
3. Apply best practices in the education of women who have sustained a TBI to facilitate recovery.

Good morning from DEN! A quick update for today: EVAWI has a new DNA series now available that might be of interest. Click through for details and links to the four bulletins:

Last week, several articles were published about new cases of drug-resistant gonorrhea cropping up in Hawaii. It’s a good reminder of the importance of being connected to your local health department and staying on top of surveillance data. As with last week’s conversation about emergency contraception, here is another issue to monitor and discuss with your team/medical director.